Informatics in Primary Care (BCS, The Chartered Institute for IT)
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Identifying the optimal search strategy for coronary heart disease patients in primary care electronic patient record systems
Get PDFObjectives General practitioners are increasingly required to practice in a paperless environment and to collect clinical data electronically on electronic patient record (EPR) systems. A principal step in meeting general practice information needs continues to be the establishment of disease registers and consequently the identification of patient populations within primary care databases is a prerequisite. This study aims to identify and validate the optimal search strategy for coronary heart disease (CHD).
Methods A multiple logistic regression model for the identification of CHD patients was developed in one site using electronic data, the receiver operating characteristic (ROC) curve and Bayesian statistics. The model was tested on two trial sites.
Results Young male CHD patients are more easily identified by generic searches than older females. The optimal search strategy for CHD was found to be the diagnostic code for CHD, nitrate and digoxin but this was dependent on the disease description, age and sex of the study population and the coding system used within the database.
Diagnostic code for CHD identified 80.6% (95% confidence interval (CI) 77-83%), 90.0% (CI 88-92%) and 95.9% (CI 94-97%) of local, national and international definitions respectively, with 100% positive predictive values (PPVs) for all definitions.
Conclusion Generic queries may inadvertently perpetuate inequalities in health care. Queries should be bespoke and mindful of the conceptualisation of disease by the clinicians recording these data
Record media used by primary care providers in medically underserved regions of upstate New York was not pivotal to clinical result in the Informatics for Diabetes Education and Telemedicine (IDEATel) project
Get PDFPurpose To examine integration of electronic medical records (EMRs) by primary care providers (PCPs) in a diabetes telemedicine project (IDEATel) in medically underserved rural areas and assess if access to digital records is associated with diabetes intermediate outcomes.
Method PCPs (n=61) with patients in IDEATel participated in structured interviews to determine current (2006 to 2007) and projected (2007 to 2008) use of paper and/or electronic medical data. T-tests examined group differences.
Results 28% (17/61) of PCPs had comprehensive EMRs, but most electronic data were noninteroperative between offices; 6% of PCPs solely used paper; 92% of PCPs used mixed paper/electronic records. Half of 61 PCPs anticipated no migration within one year to an electronic record for common patient data, while one third anticipated that function would become greatly more electronic. Among 31 PCPs interviewed in depth in person, 70% (7/10) in private practice and 69% (9/13) in networks anticipated greater electronic media migration through system change, whereas 100% of responding academic PCPs (n=6) expected only system modifications. PCPs were most interested in data exchange for chronic disease management (94%), regional benchmarking (84%) and quality improvement (87%). Patient personal electronic health records were rarely mentioned. IDEATel patients of PCPs with or without access to comprehensive EMRs achieved similar haemoglobin A1c, blood pressure, LDL-cholesterol, and body mass index, but the small number invokes cautious interpretation.
Conclusions Our findings suggest an effective and complementary element of national health information technology (HIT) strategy, telemedicine, can be implemented by PCPs with success despite the lack of a concurrent EMR for efficient data exchange
Trends in adoption of electronic health records by family physicians in Washington State
Get PDFObjective Electronic health record (EHR) adoption is encouraged by health plans, government agencies, and both the American Academy of Family Physicians and the Washington Academy of Family Physicians (WAFP), but rates of EHR adoption by family physicians in Washington were previously unknown. This study measured current rates of EHR adoption by family physicians in Washington State, as well as perceived barriers to adoption and what physicians identify as possible means to overcome those barriers.
Design A survey of medical practices in Washington State was performed. One physician per practice was selected to respond on behalf of their practice for all practices where family physicians work and for which contact information was available in the databases of the Washington State Medical Association (WSMA) and WAFP. The survey was distributed either electronically or in print form depending on availability of an email address.
Measurements Rates of EHR adoption, plans for adoption for those not yet using EHRs, perceived barriers to EHR adoption and perceived means to overcome those barriers.
Results Response rate was 43.8%. EHR adoption by this group is relatively high at 57.9%and did not vary by practice location. Although solo practices had a relatively high rate of adoption (43.5%), EHR adoption remains strongly associated with practice size. Identified barriers to implementation are primarily financial, as are the means to overcome those barriers. If current trends continue, adoption will plateau at approximately 68% in the next four years.
Conclusions Adoption rate appears to have peaked in this group given current constraints and barriers. Increased outreach efforts and assistance programs will be necessary to achieve EHR adoption in the remaining practices, particularly solo and small group practices
Leveraging time and learning style, iPod vs. realtime attendance at a series of medicine residents conferences: a randomised controlled trial
Get PDFObjective To determine whether participation in educational conferences utilising iPod technology enhances both medical knowledge and accessibility to educational content among medical residents in training.
Design/measurements In May 2007, the authors led a randomised controlled study involving 30 internal medicine residents who volunteered either to attend five midday educational conferences or to use an iPod audio/video recording of the same conferences, each followed by a five-question competency quiz. Primary outcomes included quantitative assessment of knowledge acquisition and qualitative assessment of resident perception of ease of use. Secondary outcomes included resident perception of self-directed learning.
Results At baseline, residents reported attendance at 50% of educational conferences. Of iPod participants, 46.7% previously used an iPod. During the study, 46_60% of conference attendees were paged out of each conference, of whom between 6 and 33% missed more than half of the conference. The quiz completion rate was 93%. Key findings were:
1) similar quiz scores were achieved by conference attendees, mean 60.7% (95% CI; 53.0_68.3%), compared to the iPod user group, mean 67.6% (95% CI; 61%_74.1%), and
2) the majority (10/15, 66.6%) of conference attendees stated they would probably benefit from the option to refer back to conferences for content review and educational purposes.
Conclusions Residency training programmes can optimise time management strategies with the integration of innovative learning resources into educational curricula. This study suggests that iPod capture of conferences is a reasonable resource to help meet the educational goals of residents and residency programs
Are we setting about improving the safety of computerised prescribing in the right way? A workshop report
Get PDFBackground Prescribing errors are common and costly. Technology should enable safer prescribing. The two main current methods of doing so are computer initiated clinical support software (CDSS) and the user initiated information retrieval (IR) systems. However, despite the near universal availability of computerised prescribing support in the UK, errors continue.
Objective To evaluate the experience of UK primary health care professionals using CDSS and to consolidate current technical opinion and literature in this area with the aim of creating useful hypotheses for guiding future academic investigation and industrial development.
Study design The study was a synthesis, drawing together a literature review and views from experts in the field to explore froma qualitative perspective where and how CDSS and IR could be used to improve prescribing safety in primary care. We conducted a literature review, held a workshop to explore issues in practice and had a follow-up expert panelmeeting to confirm the findings. The workshop was recorded, transcribed verbatim and analysed thematically.
Participants and setting The study involved primary care practitioners, system developers, information suppliers and academics.
Outcomes Although CDSS is incorporated into primary care electronic patient record systems there does not appear to be an associated marked reduction in prescribing errors. Clinicians are frustrated with current systems, and are concerned these may have a negative impact on patients. There is an unhelpful signal_noise ratio with too many clinically irrelevant alerts and insufficient recognition of the potential downsides of over alerting - possibly making compliance less likely, having a negative impact on the doctor_patient relationship and overloading clinicians. A preferred way forward would be alerts based on quantitative risk assessment of interaction at the level of the preparations being prescribed, rather than theoretical possibilities of interactions between classes of drugs.
Conclusion Prescribing errors remain a major source of unnecessary morbidity and mortality and current systems do not appear to have significantly reduced this problem; nor has the extensive literature about how to reduce unnecessary alerts been taken into account. We need a new and more rational basis for the selection and presentation of alerts that would help, not hinder, the clinician's performance
Personal electronic health records: from biomedical research to people's health
Get PDFAccess to web technologies and the increased bandwidth and capacity of these systems has facilitated the development of personal electronic health records (PEHRs).
This conference reports the key messages from the Friends of the National Library of Medicine (FNLM) meeting on PEHRs 'From Biomedical Research to People's Health' in May 2009.
The conference provided a comprehensive overview of issues and best practice for PEHR.
The key messages of the conference were:
PEHR have the potential to ensure equity, continuity and healthcare qualityelectronic records may allow individuals to contribute to disease surveillance, public health and research in ways that were not previously possiblewe need to prepare carefully for a 'brave new world' in which a small number of commercial organisations may become trusted custodians of the planet's medical informationethical dilemmas are already emerging from the use of PEHRs - largely stemming from our experiences within the UK.
This report links the findings of this conference with key UK and European innovations. Informaticians, in conjunction with clinicians and solution providers, should both prepare for the realities of PEHR and more formally articulate their potential benefits and risks
Hospital data may be more accurate than census data in estimating the ethnic composition of general practice populations
Get PDFBackground Equity of service provision by age, ethnicity and sex is a key aim of Government policy in the UK. The prevalence, natural history and management of common chronic conditions, such as diabetes and hypertension, vary between ethnic groups. Developing and monitoring responsive local services requires accurate measures of ethnicity and language needs. Hence establishing the ethnic composition of GP populations is important.
Objective To compare three methods of estimating the ethnic composition of GP registered populations in three east London primary care trusts (PCTs).
Design Self-reported ethnicity, routinely collected at practice level (and considered the 'gold standard'), was compared with two indirect methods of attributing ethnicity. The indirect method currently used in the UK assigns ethnicity to GP populations based on geographical postcode attribution from the national census. A proposed alternative indirect method uses the ethnic breakdown of hospital admission data from practice lists to attribute ethnicity to the whole practice population. Comparisons were made between practice self-report recording and these two indirect methods. Bland_Altman plots were used to assess the agreement between methods of measurement.
Results Data from 103 practices, covering 70% of the GP registered population, was used.
The hospital admission method showed better agreement with practice self-report data than the census attributed method. For white populations Bland_Altman plots showed a mean difference of 1.4%(95% CI _14.9 to 17.7) between hospital admission and practice data, and a mean difference of 12.5% (95% CI _6.2 to 31.1) between census attributed and practice data. Differences were also found for south Asian and black populations.
Conclusion Practice ethnicity measured using hospital attendance data is in closer agreement with practice recording of self-reported ethnicity than the census attribution method. Census attribution may provide misleading information on the ethnic composition of practice populations.
We recommend that healthcare commissioners change to this method of measurement when practice self-report data is not available
